Provider Demographics
NPI:1407259401
Name:DICKERSON, JAZMINE
Entity Type:Individual
Prefix:MS
First Name:JAZMINE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 EXECUTIVE PKWY
Mailing Address - Street 2:STE 7 #280
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3550 EXECUTIVE PKWY
Practice Address - Street 2:STE 7 #280
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1379
Practice Address - Country:US
Practice Address - Phone:313-409-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154998164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse